Click photo to enlarge
Dr. Mark Vierra is a board certified general surgeon and specializes in... (COURTESY OF CHOMP)
Bev Schiavoni wasn't the typical patient walking into the office of a weight-loss surgeon.
She wasn't focused on losing weight as much as removing 40 pounds of skin from dropping a great deal of weight through nutrition and exercise.
Yet for Dr. Mark Vierra, Schiavoni was just the kind of patient he needed. Vierra, who helps run the bariatric surgery center at Community Hospital of the Monterey Peninsula, wants patients to understand that proper nutrition and exercise are key to keeping the weight off.
"He was my hero, and I was his," Schiavoni said.
Nutrition became integral to Vierra's treatment for his patients when he started in metabolic surgery at Stanford University in 1990. Many of his patients had a "complicated nutritional background" from cancer treatments or injuries that left them unable to absorb nutrients. He helped them gain weight through nutritional counseling.
At the same time, he started fielding patients who wanted to lose weightthrough surgery.
"I learned a lot about weight control because of studying the extremes," he said.
One-third of Americans are obese, according to the Centers for Disease Control and Prevention. Though we spend significantly more on diet foods and diet programs than other countries, "We are getting fatter and fatter," he said.
The discrepancy indicates dieting is not the answer to weight control, Vierra said. "Very few people on any commercial diet program lose weight and keep it
Advertisement
off."That includes contestants on the television program, "The Biggest Loser."
"I don't like the idea of the show because it emphasizes weight loss in a hurry," he said. One winner came to Vierra's seminar because he had regained the weight, he pointed out.

Multiple issues

Hormonal control during weight loss complicates issues. For instance, if a patient has an enormous amount of the stomach-producing hormone called ghrelin, they are typically obese. However, ghrelin, which is found to amplify the feeling of being hungry, can actually increase during dieting.
Most dieters also hit a plateau — once they reach a certain weight, it's an uphill battle to lose more.
"The more weight you lose, the harder it is to keep that weight off," Vierra said.
One study showed that six weeks after subjects lost 10 percent of their body weight, the body's metabolism slowed to burn 300 fewer calories. Without the extra weight, the body requires fewer calories and becomes more efficient at burning them.
This efficiency in metabolism is akin to switching from a gas-guzzler to a hybrid. Though the hybrid burns less fuel, there is much less power to help climb the hill (i.e., shave off additional pounds).
To get past that plateau, people must not only cut their calorie intake far more than just 300 calories, but also continually ramp up their exercise program — a discouraging prospect for many dieters.
Kevin Hall, an obesity researcher from the National Institute of Diabetes and Digestive and Kidney Diseases, illustrates this metabolic dilemma through mathematics. He created a model based on years of controlled feeding studies to simulate a more realistic picture of what to expect when changing one's diet. He published his research in The Lancet in August 2011.
"We've known for decades that if you cut the calories in someone's diet, their metabolism slows down," Hall said.
The simulation takes into account how metabolism adapts during weight loss. By plugging in sex, age, weight, height, and answering questions about physical activity, the model predicts what realistic changes of diet or exercise are needed to achieve the goal weight. And more importantly what to do permanently to maintain that weight loss," Hall said.
He notes that people are successful in short-term weight loss (most of it as water weight), but fail to maintain that loss over time.
His model also upsets the dieting rule of thumb that even his own institution prescribes, which states a daily 500-calorie restriction equates to losing a pound a week, and that this type of loss should continue. Not only does this approach overestimate weight loss, but it fails to address how to sustain that weight. Weight loss is not linear, he explains, but gradually slows over time. With variations in people's activity levels, percentage and location of body fat, initial weight, etc. .. it can get complicated, Hall said.
Instead of the 3,500 calories per pound, one can expect to lose half the target weight in a year, and achieve the goal weight within three years.
Though the simulator is meant for researchers and dietitians, Hall's goal is to develop it into a more public-friendly tool that translates the predicted calories into actual foods. In the meantime, it gives people an idea of whether their weight-loss goals are reasonable.

Changing environments

Vierra notes the success of his patients who lost weight without surgery — they changed their environment, and left a lifestyle that perpetuated unhealthy habits.
Making critical life changes comes not only with restructuring our environment, such as changing jobs, he said, but being aware of the ubiquitous processed food we consume that has a "seductive secret sauce of salt, fat and sugar."
Schiavoni did just that.
Weighing 440 pounds in her early 50s, she faced the prospect of dying. And that woke her up.
"I wanted to see my grandkids grow up," she said.
Now at 70 and 250 pounds lighter, she attributes this loss to a change in lifestyle, food, and getting a golden retriever.
Casey, her walking partner of 13 years, accompanied Schiavoni two or three miles each day — and didn't allow her to skip walking him.
" I walked real early in the morning, because I am lazy about exercise. If I don't do it then I will find a 101 excuses why not to do it," she said. "If you just get out there and do it, then it's out of the way for the day."
Though her dog passed away last year, she continues to walk among the early morning exercisers who tell her, "You don't look right without your dog."
With the encouragement of Weight Watchers and their recipes, she learned to alter the amount of food she ate, never ate past 7 p.m., removed cake, candy and ice cream from her diet, switched to unfried fish and chicken, and consumed more fresh fruit and vegetables. Once she began taking care of herself, she felt better and even started shopping — something that she hadn't done for many years.
Schiavoni discussed bariatric surgery at one point with Vierra, though she noticed that those who underwent the procedure put the weight back on. It may jump-start a 100- to 200-pound loss, but if they don't alter their lifestyle to do what Schiavoni is doing, it doesn't matter, she said. "I know Dr. Vierra really stresses it, but I don't think people really hear it."
What Schiavoni empathizes with most is that her brain and the brain of those who are overweight respond very differently to food. "Food is a serious addiction. We have to eat to survive," she said.

Fast food dilema

For Vierra, convincing people about the ins and outs of fast food frustrates him the most.
"Making lunch or grabbing an apple and yogurt is so much faster, so much cheaper and so much healthier than going through a drive-through," he said.
Though many families claim to not have time or money to eat healthy, Vierra said it only takes some advance planning and simple cooking. Learning to make a healthy alternative to fast food, such as a lentil stew for $20, can feed a family for several meals.
Like his favorite food author, Michael Pollan, whose books Vierra suggests his patients read, Vierra pushes for eating local, nutritious whole foods. He, too, would like to see subsidies decrease for crops that are of little nutritional value, such as corn.
"We pay more attention to how we feed our pets than we do ourselves," Vierra said. "If there was Coca-Cola and Captain Crunch for the dog, you'd call the SPCA, but we think it's perfectly fine to feed our children."

Vierra is a board certified general surgeon and specializes in bariatric surgery. His office is in Ryan Ranch in Monterey and he has been a member of Community Hospital's medical staff since 2001.
Weight-loss talk

For people who are considering a surgical approach to weight loss and improved health, Dr. Mark Vierra offers a free monthly lecture on the biological basis for obesity, strategies for weight loss and surgical options.

When: 7 to 8:30 p.m. the first Thursday of each month
Where: Main conference room at Community Hospital of the Monterey Peninsula, 23625 Holman Highway, Monterey
Information: 649-0808